A Safer Place for Patients: Learning to Improve Patient Safety; Fifty-first Report of Session 2005-06; Report, Together with Formal Minutes, Oral and Written Evidence
The Stationery Office, Jul 6, 2006 - Law - 43 pages
Everyday the NHS successfully treats over 1 million people. However there are risks and treatments can go wrong. A report by the Chief Medical Officer in 2000, ('An organisation with a memory', ISBN 0113224419) estimated that one in ten patients admitted to hospital were unintentionally harmed and that a blame culture and lack of a national system for sharing experience were key barriers to reducing the number of patient safety incidents. In Government's response included plans, timetables and targets to promote patient safety and the establishment of the National Patient Safety Agency. This report finds that insufficient progress has been made. In particular there is a question mark over the National Patient Safety Agency because of cost over-runs and delays in its National Reporting and Learning System and the limited feedback it has so far provided to trusts.
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anonymous Bacon blame culture C&AG's Report Chairman Chief Medical Ofﬁcer classiﬁcation clinical governance Committee of Public contributory factors countries deaths Department of Health developed Edward Leigh evaluated fair culture feedback ﬁeld ﬁgure ﬁnd ﬁrst Greg Clark harm Health and National Healthcare Commission Helen Goodman hospital identiﬁed improve patient safety incidents per 1,000 incidents reported independent sector issued Jon Trickett Khan Kitty Ussher Learning System learning to improve Medical Ofﬁcer’s medication errors members of staff mental health trusts million MP Labour NAO Report National Audit Ofﬁce National Patient Safety National Reporting NHS trusts NPSA budget number of incidents open and fair organisation paragraph Patient Safety Agency patient safety incidents Professor Sir Liam programme reﬂected reported incidents Reporting and Learning Richard Bacon safety alerts safety culture Sir Liam Donaldson Sir Nigel Crisp solutions speciﬁc staﬂ taxonomy trust level trusts reported under-reporting value for money Williams